1. case information: patient Zhao Wennian, male, 69 years old. He was admitted to the hospital on 2013-08-10 and discharged on 2013-09-13 mainly because of chronic cough and sputum for 3 months. He had been cured of “hyperthyroidism” 50 years ago, “diabetes mellitus” for 5 years, and “alcoholic liver” for 3 years. In July 2013, he was diagnosed as “alcoholic hepatitis followed by cirrhosis, hepatic decompensation and ascites formation”. Chest CT performed during hospitalization showed patchy, honeycomb-like high-density shadows with adhesions to the pleura in both lungs. The sputum was positive for antacid bacilli (+), and he was considered to have tuberculosis and was transferred to our hospital for treatment. On admission: T 37.2℃ P 92 times/min R 23 times/min BP 98/54mmHg SO2 87% chronic wasting disease capacity, weak breath sounds in both lungs, wet rales heard in both lungs, left lung was predominant, heart rhythm was uniform, abdominal tension, no pressure pain and rebound pain, liver and spleen were not palpable, positive mobile turbid sounds, mild edema in both lower limbs and both feet. The laboratory indices were as follows: routine blood WBC16.15×109/L HGB125g/L Pts247×109/L NEUT85.1%; liver function AST46U/L ALB26.3g/L TBIL21.20μmmol/L DBIL9.35μmmol/L ALP160 U/L r-GT130 U/L CHE2719 U/L TBA34μmmol/L; blood gas analysis PH7.477 PO247 mmHg SO285%; serum electrolytes potassium3.05mmol/L CI89.2mmol/L; ASO positive. Multiple sputum cultures after admission returned fungal growth. Admission diagnosis: secondary pulmonary tuberculosis in both lungs Tu(+) primary treatment secondary pulmonary infection type 1 respiratory failure post-alcoholic hepatitis cirrhosis hepatic failure hypoproteinemia ascites formation tuberculous peritonitis? Anemia Electrolyte disorders Type 2 diabetes mellitus. 2. Case analysis: The diagnosis of this patient is basically clear according to the characteristics of the medical history. But the treatment is relatively difficult, from the above case situation must deal with the following issues: 1. liver function problems; 2. anti-TB problems; 3. blood sugar problems; 4. ascites problems; 5. lung infection problems liver preservation or anti-TB, which is more important? Firstly, the choice of hepatoprotective drugs is not the better, but the drugs with definite efficacy on the liver are selected according to experience, so reduced glutathione is preferred, and other drugs are combined if necessary; secondly, the choice of anti-TB drugs is based on experience, and isoniazid and ethambutol are the first-line drugs with relatively little liver damage, and are preferred. The choice of quinolones was relatively inexpensive, and levofloxacin had both anti-infective effects and few side effects, and liver damage was not obvious, so it was chosen. The choice of drug is very simple, insulin – the only choice and the absolute indication. Among them, short-acting insulin is preferred, which is easy to control and regulate at the right time. The insulin dosage is gradually adjusted according to the monitoring of blood glucose. Effective blood glucose control is a key component of TB lesion absorption. To address ascites, the cause of ascites needs to be determined, hypoproteinemia due to? tuberculous peritonitis? Therefore, laparotomy must be done. In principle, pumping and releasing ascites is generally not advocated in the period of liver function loss, but with the protection of anti-infective and glucose-lowering therapeutic measures, laparotomy should be safe, so closed abdominal drainage should be performed to drain the abdominal fluid and retain the abdominal fluid for examination to clarify the nature of ascites. However, regardless of the cause, correction of hypoproteinemia as soon as possible is necessary to promote the absorption of ascites without harm. The problem of pulmonary infection, because of the consideration of his high blood picture, obvious wet rales in the lungs and positive ASO suggesting streptococcal infection, is preferred to penicillin anti-infective treatment, and penicillin basically does not need to worry about the effect on liver and kidney. Multiple sputum cultures returned fungal growth, and antifungal drugs, the impact on the liver does not allow to underestimate. However, there was no choice but to use fluconazole orally with close monitoring of liver and kidney function. In this case, under the above careful and close observation and care, anti-TB and other treatments were carried out smoothly, and the lung CT was reexamined at the end of 1 month, and the lesions were better absorbed than before, and ascites was significantly absorbed. Afterwards, the family automatically requested to be discharged. Through the above case, the lesson I learned is that, when encountering seriously ill patients, as long as careful analysis and strict standardized treatment measures are taken, there is hope to achieve satisfactory results.